What is it?

There are several different approaches that a surgeon will use to correct spinal deformity such as scoliosis and kyphosis, including the traditional posterior approach, an anterior approach, or both. The anterior approach to scoliosis means that the surgeon will approach the spinal column from the front of the spine rather than through the back.

Technically speaking, the actual surgical incision and approach to the spine is through the side of the chest or abdomen (stomach area) rather than down the front of your body, as many patients would envision it. The anterior approach allows surgeons to remove discs from the front of the spine, place corrective spinal instrumentation and perform a spinal fusion.

Why is it done?

The choice of an open anterior approach to the spine is based on a number of different factors including the type of scoliosis, location of the curvature of spine, ease of approach to the area of the curve, and the preference of the surgeon. There are certain types of scoliosis curves, such as those involving the thoracolumbar spine, that are especially amenable to the anterior approach. The surgeon may be able to fuse a shorter segment of the spine using the anterior approach, preserving more motion in the spinal column.

Anterior instrumentation techniques can produce very powerful correction of spinal deformities. However, this approach is more difficult than the standard posterior approach.

The Operation

The first thing that happens after you enter the operating room is that your anesthesiologist will help you to fall asleep. Once you are completely asleep, the anesthesiologist will place a breathing tube to assist with your breathing during surgery, establish a variety of catheters in your veins, and often an arterial catheter in your wrist, all of which allow for monitoring of heart function, blood pressure, fluid status, and the depth of anesthesia during your operation. This allows the anesthesiologist to be sure that you remain completely asleep during the operation. Once this is completed, the patient is rolled onto their side, with the operative side facing up, into what is termed the "lateral decubitus position."

Incision

The incision is made on the patient's side. Depending on the part of the spine that requires correction, this may be over the chest wall or lower down along the abdomen. The surgeon deflates the lung and removes a rib in order to reach the spine. Most patients find it interesting that the rib will grow back over time, especially if you are young. For lower incisions, the surgeon may need to detach the diaphragm to gain access to the spine, especially for thoracolumbar curves and those in the lumbar spine.

Spinal Preparation
Once the surface of the spinal column is exposed, the surgeon will often remove the disc material from between the vertebra involved in the curve. This will increase the flexibility of the curve and provide a large surface area for spinal fusion. Disc removal is an important adjunct to the anterior correction of scoliosis.

Screw and Rod Placement
Placing instrumentation in the front of the spine completes correction of the spinal deformity. This usually consists of placing a vertebral body screw at each vertebral level involved in the curve. These screws are then attached to a single or double rod at each level. A combination of compression along the rod, and rotation of the rod will produce correction of the spinal deformity.

Fusion
After the final adjustment and tightening of the instrumentation, a fusion is performed. The bony surface between the vertebral bodies is roughened and bone graft is packed into the space between the vertebral bodies. There are a variety of different sources for bone graft including the removed rib, the crest of the pelvis, allograft bone, and other bone substitutes.

Incision Closure
The incision is closed and dressed. If the surgeon has been in the chest cavity, then it will be necessary to place a chest tube through the side of the chest to help keep you lung expanded after the surgery.

What is it?

There are different techniques and methods used today for scoliosis surgery. The most frequently performed surgery for idiopathic adolescent scoliosis involves posterior spinal instrumentation with fusion. This kind of surgery is performed through the patient's back while the patient lies on his or her stomach.

Why is it done?

The Posterior approach was designed to correct the abnormal curves in the spine that occur in the condition known as "scoliosis." The posterior approach is the most traditional approach to the spine for spinal surgery. The majority of spinal operations are done using this approach.

The Operation

The first thing that happens after you enter the operating room is that your anesthesiologist will help you to fall asleep. Once you are completely asleep, the anesthesiologist will place a breathing tube to assist with your breathing during surgery, establish a variety of catheters in your veins, and often an arterial catheter in your wrist, all of which allow for monitoring of heart function, blood pressure, fluid status, and the depth of anesthesia during your operation. This allows the anesthesiologist to be sure that you remain completely asleep during the operation. Once this is accomplished, the patient is placed on their stomach and their arms and legs carefully padded.

The Incision
An incision is made down the middle of the back. The location and length of the incision depend on the location of the curve and the extent of the exposure that are required to correct it. The incision is often made slightly longer than the length of the planned fusion.

Hooks, Screws and Rod Placement
Correction of the scoliosis requires that the surgeon be able to "grab on" to the spine. There are a variety of ways to do this. Technically, the surgeon may choose to use hooks that attach to the back of the spine on the lamina, pedicle screws that are placed into the pedicle in the middle of the spine, wires, or other devices. Once these connection points are established, then a rod that has been bent or contoured into a more normal alignment for the spine can be attached and correction performed.

Final Tightening
When all of the implants are securely in place a final tightening is done.

Incision Closure
The incision is closed and dressed. Some surgeons may choose to place a drain into the wound after the surgery to protect the incision. Patients wake up in their hospital bed lying on their back.

What is it?
There are a variety of different approaches to correction of spinal deformity. Surgeons make decisions regarding the type of surgery that is appropriate for your case depending on the type, severity, and location of your particular spinal curve. In certain types of deformity, your surgeon may recommend that you have what is termed a "front and back" or anterior-posterior spinal surgery.

Why is it done?
Anterior and posterior surgery is generally recommended for curves that are very severe, stiff, or when you have failed previous attempts at fusion.

The Operation

The first thing that happens after you enter the operating room is that your anesthesiologist will help you to fall asleep. Once you are completely asleep, the anesthesiologist will place a breathing tube to assist with your breathing during surgery, establish a variety of catheters in your veins, and often an arterial catheter in your wrist, all of which allow for monitoring of heart function, blood pressure, fluid status, and the depth of anesthesia during your operation. This allows the anesthesiologist to be sure that you remain completely asleep during the operation.

The Incision

Anterior and posterior surgery requires that the surgeon will first approach your spinal column from the front. In order to do this, the surgeon will usually make an incision on your side. The surgeon will then remove the disc material from between the vertebrae in the most severe part of your curve to make your curve more flexible and facilitate fusion. This part of the procedure often requires removal of a rib that is then used for bone graft.

After the anterior part of the procedure is completed, the wound is closed and you are then positioned for the "back" or posterior part of the procedure. The deformity is then corrected with placement of spinal instrumentation in your back followed by a posterior fusion.

Hooks, Screws and Rod Placement
Correction of the scoliosis requires that the surgeon be able to "grab on" to the spine. There are a variety of ways to do this. Technically, the surgeon may choose to use hooks that attach to the back of the spine on the lamina, pedicle screws that are placed into the pedicle in the middle of the vertebra, wires, or other devices. Once these connection points are established, then a rod that has been bent or contoured into a more normal alignment for the spine can be attached and correction performed.

Final Tightening
When all of the implants are securely in place a final tightening is done.

Incision Closure
The incision is closed and dressed. Some surgeons may choose to place a drain into the wound after the surgery to protect the incision. Patients wake up in their hospital bed lying on their back. Most patients who have had anterior and posterior surgery will require care in the Intensive Care Unit after surgery.

What is it?

The endoscopic system for scoliosis correction was designed to allow the surgeon to accomplish all of the goals of a traditional "open" anterior procedure, with less trauma to the muscles of the back and the rib cage. Endoscopic anterior scoliosis surgery is accomplished through the use of multiple incisions or "portals" made in the side of the chest cavity that allow the surgeon to insert instrumentation into the vertebral bodies and perform a fusion. This procedure is often referred to as being "Minimally Invasive", because the surgeon uses several small incisions to perform the surgery compared to a single longer incision. There are several advantages of using an endoscopic system including an improved visualization of the involved anatomy inside the chest cavity and greater flexibility to place instrumentation in the anterior aspect of the spine.

Why is it done?

Endoscopic scoliosis surgery is not for everyone or every curve. There are certain forms of scoliosis that are particularly amenable to endoscopic correction, especially curves only involving the thoracic spine. Lumbar and thoracolumbar curves are better approached with a more traditional open technique. The CD HORIZON® ECLIPSE™ Spinal System was designed specifically for the endoscopic approach in the thoracic spine.

The Operation

The first thing that happens after you enter the operating room is that your anesthesiologist will help you to fall asleep. Once you are completely asleep, the anesthesiologist will place a breathing tube to assist with your breathing during surgery, establish a variety of catheters in your veins, and often an arterial catheter in your wrist, all of which allow for monitoring of heart function, blood pressure, fluid status, and the depth of anesthesia during your operation. This allows the anesthesiologist to be sure that you remain completely asleep during the operation. Once this is completed, the patient is rolled onto their side, with the operative side facing up, into what is termed the "lateral decubitus position."

A special radio lucent operating table is used that allows the surgeon to take x-rays during the procedure with a fluoroscope. This is needed to make the incisions in the proper place and at the correct level of the spine.

Endoscopic surgery requires an accomplished surgical team consisting of two operating surgeons, scrub nurses, monitoring personal, and an anesthesiologist that is skilled in single lung ventilation. All must work in concert to make the surgery safe and efficient.

The Incision
IncisionsThree to five incisions are made depending on the location of the scoliosis curvature, number of levels that will be operated on and the ability to visualize the spine for the safe placement of the spinal instrumentation.

Discs Removed
The pleura is incised and retracted from the vertebral bodies. Once the surface of the spinal column is exposed, the surgeon will often remove the disc material from between the vertebra involved in the curve. This will increase the flexibility of the curve and provide a large surface area for spinal fusion. Disc removal is an important adjunct to the anterior correction of scoliosis.

Rib Graft

Once all of the discs are removed, rib graft is harvested. There is usually an adequate amount of bone graft that can be harvested from the ribs. It is not necessary that the entire rib be removed, so a normal contour to the chest can be maintained. In certain situations where the ribs are very prominent, forming a "rib hump", the ribs can be removed endoscopically and improve the cosmetic outcome of the procedure. This is known as a "Thoracoplasty".

Screw Placement

Screw PlacementScrews are placed in the anterior vertebral body under the visual guidance of the endoscope and the fluoroscope. Once all of the screws are in place, the disc space is filled with bone graft.

Compression

CompressionA rod, cut to length, is inserted into the chest cavity and attached to the screws. Once the rod has been attached to the screws, correction is accomplished by performing a compression maneuver between the screws.

Closing the Incision

The five small incisions are closed. Once healed the scars are cosmetically small and less noticeable than a traditional scoliosis scar. Since the surgeon was in the chest cavity, a chest tube will often be used to keep the lung expanded and healthy after surgery.

It is important that you discuss the potential risks, complications, and benefits of CD HORIZON® ECLIPSE® Spinal System with your doctor prior to receiving treatment, and that you rely on your physician's judgment. Only your doctor can determine whether you are a suitable candidate for this treatment.

As you prepare yourself mentally to undergo spinal surgery, you also need to prepare yourself for the recovery period that will follow your operation. While the surgery entails work on the part of the surgeon, after that, the brunt of the work is in your hands. To ensure a smooth and healthy recovery, it is important that, as a patient, you closely follow the set of instructions that your surgical team gives you.

Hospital Recovery

After the operation, you will be brought to the recovery room or intensive care unit (ICU) for observation. When you wake up from the anesthesia, you may be slightly disoriented, and not know where you are. The nurses and doctors around you will tell you where you are, and remind you that you have undergone surgery. As the effects of the anesthesia wear off, you will feel very tired, and, at this point, will be encouraged to rest.

Members of your surgical team may ask you to respond to some simple commands, such as "Wiggle your fingers and toes" and "Take deep breaths." When you awaken, you will be lying on your back, which may seem surprising, if you have had surgery through an incision in the back; however, lying on your back is not harmful to the surgical area.

Prior to the surgery, an intravenous (IV) tube will be inserted into your arm to provide your body with fluids during your hospital stay. The administration of these fluids will make you feel swollen for the first few days after the operation.

When you awake from the anesthesia, you may feel the urge to urinate. So, in addition to the IV, a catheter tube (also commonly called a Foley Catheter) may be placed into your bladder to drain urine from your system. The catheter serves two purposes: (1) it permits the doctors and nurses to monitor how much urine your body is producing, and (2) it eliminates the need for you to get up and go to the bathroom. Once you are able to get up and move around, the catheter will be removed, and you can then use the bathroom normally.

During your hospital stay, you will get additional instructions from your nurses and other members of your surgical teams regarding your diet and activity.

Proper nutrition is an important factor in your recovery. Your surgeon may restrict what you drink and eat, or place you on a special diet, depending on the surgical approach that was used during the operation. Calories and food intake are an important part of recovery. Some patients find that their physician orders are less restrictive than the diet they follow at home. After the surgery, you will continue to receive intravenous fluids until you are able to tolerate regular liquids, which typically involves gradually transitioning you from sips of clear fluids to full liquids (including JELL-O® gelatin). From there, you will be given small amounts of solid food until you are ready to return to a regular diet.

With respect to physical activity, in most cases, your surgeon will want for you to get out of bed on the first or second day after your surgery. Nurses and physical therapists will assist you with this activity until you feel comfortable enough to get up and move around on your own.

Home Recovery

Before you are discharged from the hospital, your doctor and other members of the hospital staff will give you additional self-care instructions for you to follow at home - a list of "dos and don'ts," which you will be asked to follow for the first 6 to 8 weeks of your home recovery. So, if you are unsure of any of these instructions, ask for clarification. Following these instructions is crucial to your recovery.

Nowadays, surgery involves one or more incisions depending on the surgical approach used to perform the operation. Therefore, when you are discharged home you may still have a surgical dressing on your incision(s). Either a nurse will visit your home to change the dressing or a caregiver, such as one of your family members, will be taught to do it for you. It is important that the dressing be changed daily and kept dry.

If any signs of infection are observed while changing the dressing, call your doctor. These signs include:

• Fever - a body temperature greater than 101°F (38°C)
• Drainage from the incision(s)
• Opening of the incision(s), and
• Redness or warmth around the incision(s).

In addition, call your doctor if you experience chills, nausea/vomiting, or suffer any type of trauma (e.g., a fall, automobile accident).

During this recovery period, you will also be instructed to keep your incision(s) clean, making sure only to use soap and water to cleanse the area. In general, you should not shower until your doctor has permitted you to do so.

In addition to caring for your incision(s), you will also be encouraged to:

• Drink plenty of fluids
• Maintain a healthy diet (high in protein)
• Walk or do deep-breathing exercises, and
• Gradually increase your physical activity.

Activities to avoid include any heavy lifting, climbing (including stairs), bending, or twisting. You should also avoid the use of skin lotion in the area of the incision(s); you need to keep this area dry until it has had the opportunity to heal well.

Follow up with your doctor on a regular basis during this post-operative period, and make sure to call your doctor if you have any concerns or questions.